Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update

Clinician views on acupuncture for acute pain care in a busy urban emergency department

INTRODUCTION

Opioid misuse and dependence remain critical public health issues in the U.S., contributing significantly to reduced life expectancy. Emergency departments (EDs) are key settings for implementing opioid reduction strategies when treating acute pain, such as nonpharmacologic treatment options like acupuncture. This study explored clinician-related factors influencing the integration of the Pain Elimination through Acupuncture Research and Learning (PEARL) program for pain reduction within a high-volume urban ED.

METHODS

This study employed a sequential mixed methods design, involving surveys and interviews with ED clinicians. An 11-item electronic survey was administered annually to assess clinician attitudes related to appropriateness and effectiveness of integrating acupuncture into the ED's comprehensive care plan for treatment of pain. Near the end of the 3rd year of the PEARL program, semi-structured interviews were conducted to gather in-depth insights into clinician knowledge and perceptions of the program.

RESULTS

Quantitative survey data from 99 eligible ED clinicians indicated positive perceptions of the program's appropriateness and effectiveness, and improved understanding of acupuncture referral procedures. Analysis of qualitative interviews conducted with 16 ED clinicians revealed five key themes: acupuncture as an acceptable analgesic strategy to reduce the use of opioids, patient benefits, program presence in the ED, integration challenges, and the need for continued education.

CONCLUSION

Strong acceptance of acupuncture as a feasible nonpharmacologic addition to the comprehensive pain care plan used in the ED was observed. Dedicated space, expanded acupuncture staff and hours, and ongoing training of ED staff will require institutional support to sustain acupuncture as a nonpharmacologic treatment option for ED patients.

Strategies for Pain Management in Hepatocellular Carcinoma Patients Undergoing Transarterial Chemoembolisation: A Scoping Review of Current Evidence

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality, with transarterial chemoembolisation (TACE) being a primary treatment for intermediate-stage disease. However, post-procedural pain remains a significant challenge due to inconsistent management practices and a lack of standardised protocols. This scoping review synthesises current evidence on pain management strategies in HCC patients undergoing TACE, evaluates their effectiveness, identifies practice gaps, and proposes optimisation strategies. Methods: A comprehensive database search according to the methodological approach given by Arksey and O'Malley with the aid of the PRISMA-ScR guidelines across Cochrane Library, Web of Science, CINAHL, PubMed, and Scopus was performed. The terms associated with pain, TACE, and liver cancer were included in the search strategy. Two independent researchers systematically screened study titles, abstracts, and full texts and extracted key study characteristics and approaches to pain management. Results: Of 1515 identified studies, 29 met the inclusion criteria. Most (72.7%) focused on pharmacological interventions, with dexamethasone and lidocaine being the most frequently investigated agents. Non-pharmacological approaches, including psychological interventions, physical therapies, music therapy, health education, and comprehensive nursing, were also reported. Pain was primarily assessed using the visual analogue scale (VAS) and numeric rating scale (NRS). Conclusions: Pharmacological interventions, particularly dexamethasone and lidocaine, remain the cornerstone of pain management in TACE, yet consensus on their optimal use is lacking. Non-pharmacological strategies provide complementary benefits. standardised, evidence-based pain management protocols integrating both approaches are needed. Future large-scale, multicentre trials are essential to establish the most effective strategies for optimising patient outcomes.

The majority of Norwegian patients with treatment-resistant chronic pain regained normal national health standards within 12 months after De-Qi acupuncture - a prospective observational propensity score matched study

Purpose

In previous studies, acupuncture was effective in the treatment of patients with chronic pain that was unresponsive to conventional therapies. However, the proportion of patients in a real-world setting who regain normal health after 1 year, following De-Qi acupuncture is unknown.

Methods

This is an observational prospective study of 354 new patients in a family medical practice between 2015 and 2018. Patients self-assessed pain using the Visual Analogue Scale (VAS), and health using the Short Form 36 Health Survey (SF-36) before treatment and at 3- and 12-months of follow-up. VAS and SF-36 components were compared for improvements and therapeutic effect sizes. Propensity score matching was employed to avoid bias by confounding variables.

Results

The participation rate was 29%, median age 50 years (range 20-79), 65% were females, median pain duration was 18 months (6-360), the median number of acupuncture treatments was 6 (1-27). The initial VAS pain intensity of 6.2 (SD 2.5) improved to 4.0 at 3 months and 3.2 at 12 months (p < .001, large effect size); SF-36 scores also improved. 75% of patients showed strong responses, with 58% reaching complete cure and 17% achieving near-normal health. Patients aged >65 responded well and ≥6 treatments were associated with stronger responses than 1-5. Hill criteria analysis of improvements with acupuncture suggested causation over association.

Conclusion

In patients with chronic pain (median 18 months), who were unresponsive to conventional treatments, De-Qi acupuncture was associated with sustained pain reduction and health improvements. Most attained Norwegian national normal health standards (complete cure) after 12-months.

Challenges and Issues in Acupuncture Education in Malaysia

Background

Acupuncture, a traditional Chinese medicine (TCM) practice, has become globally recognized as a complementary therapeutic approach for various health conditions. In Malaysia, acupuncture occupies a significant role in the country's diverse healthcare system, reflecting its cultural heritage. However, the education and training of acupuncture practitioners face numerous challenges, including variability in educational approaches, accreditation, and integration with conventional medical practices.

Objective

This article aims to explore the complexities of acupuncture education in Malaysia, providing an overview of the current landscape. It addresses the regulatory frameworks, educational challenges, and the implications these have on professional standards and patient care. The article also highlights potential solutions for improving acupuncture education in the country.

Methods

A comprehensive review of existing literature, regulatory frameworks, and educational practices related to acupuncture in Malaysia is presented. The article examines the variability in training programs, accreditation standards, and the integration of acupuncture with conventional healthcare models.

Results

The education and training of acupuncture practitioners in Malaysia are hindered by inconsistent curricula, lack of standardized guidelines, and differing levels of accreditation. These challenges contribute to variations in educational quality across institutions, complicating efforts to ensure competent practitioners. Furthermore, acupuncture's integration with mainstream medical practices remains unclear, affecting its overall acceptance and effectiveness within the broader healthcare system.

Conclusion

Addressing the challenges in acupuncture education is crucial for enhancing the competence of practitioners and ensuring quality patient care. Key areas for improvement include the standardization of curricula, strengthening accreditation processes, promoting interdisciplinary collaboration, and increasing public awareness. Proactive efforts in these areas can enhance the quality of acupuncture education in Malaysia and foster better integration of acupuncture into the national healthcare framework.

Acupuncture in Pediatrics: A Scoping Review

Background: The use of acupuncture for common pediatric conditions continues to grow in the United States. Six previous reviews have summarized the research; however, approximately 8 years have accumulated adding to this growing body of literature. Objectives: The aim of this article is to provide a scoping review of acupuncture research in pediatric conditions and a summary of the effectiveness of acupuncture in the pediatric population. Methods: A systematic search was performed to identify clinical trials and reviews published between August 2015 and October 2023. Trials and reviews were excluded if they were not: (1) acupuncture specific, (2) data limited to pediatric patients, and (3) published in English. The literature was assessed and synthesized into a scoping review and commentary. Results: Seventy-one publications were identified (42 clinical trials and 29 reviews) that represented 17 conditions and 10 countries; the top 2 were China and the United States. The top five areas of new research (based on numbers of clinical trials) are pain, cerebral palsy (CP), attention-deficit hyperactivity disorder, autism spectrum disorder, and nausea and vomiting. Conclusions: Clinical trials in pediatric acupuncture represent a small but important subset of acupuncture literature. Data are positive for postoperative nausea and vomiting and promising for CP, nocturnal enuresis, perioperative pain, procedural pain, and tic disorders. Several factors preclude additional firm conclusions from being drawn, including a limited number of trials, small sample size (n < 100) of the majority of randomized controlled trials (78.6%), and heterogeneity of treatment approaches. Continued research on the use of acupuncture for pediatric conditions is warranted, particularly in conditions demonstrating recent promising evidence.

Acupuncture in Dentistry: A Comprehensive Review of Its Applications, Mechanisms, and Clinical Efficacy

The ancient therapeutic practice of acupuncture, which has its roots in traditional Chinese medicine, has drawn a lot of interest lately due to its possible use in contemporary dentistry. Examining the mechanics, clinical effectiveness, and contemporary uses of acupuncture in dentistry is the goal of this review. We evaluate its impact on the healing process, surgical recovery, anxiety management, and dental pain. However, more thorough and well-planned randomized controlled trials are still required to confirm its therapeutic advantages. The aim of this review is to explore acupuncture's mechanisms of action, including endorphin release, autonomic nervous system regulation, and effects on local blood circulation, along with how it may be included in a comprehensive dental care plan.

A comprehensive overview of acupuncture therapy over the past 20 years: Machine learning-based bibliometric analysis

BACKGROUND

Acupuncture, a therapy created by the ancient Chinese, has been gaining increasing popularity and acceptance worldwid. The surge in the number of publications on acupuncture therapy has posed significant challenges for researchers in effectively managing the vast amount of information. This study aimed to analyze the themes and topics of the scientific publications related to acupuncture therapy in the past two decades by machine learning.

METHODS

The MeSH term "Acupuncture Therapy" was used for searching publications from 1st January, 2004-31 st December, 2023 on the PubMed database, while the R platform was adopted to obtain associated data. A topic network was constructed by latent Dirichlet allocation (LDA) and the Louvain algorithm.

RESULTS

A total of 17,584 publications were finally recruited in this article. The publications were derived from 57 countries, with China, The United States and England being the top three countries. "Acupuncture Points", "Treatment outcome", "Electroacupuncture" were the most concerned MeSH terms. Four clusters and 50 branched topics were recognized by LDA and network analyses. "Comparative Efficacy", "Biochemical Analysis", "Symptomatic Treatment", "Professional Practice" and "Clinical Trials" are hotspots identified by LDA. "Neurotransmitter", "Meta-Analysis" and "Literature Review" have presented as new research hotspots.

CONCLUSIONS

Acupuncture therapy has obtained increasing attention over the past two decades. Most of the studies focus on the mechanisms especially the analgesic and anti-inflammatory mechanisms, more researches such as "Neurotransmitter" will continue to advance. Besides, "meta-analysis" and "literature reviews" are increasingly common, providing more comprehensive and credible evidence for acupuncture therapy.

Complementary Approaches to Postoperative Pain Management: A Review of Non-pharmacological Interventions

Postoperative pain significantly affects many surgical patients. While opioids are crucial for pain management, they come with unwanted side effects. Alternatives like nonsteroidal anti-inflammatory drugs, N-methyl-D-aspartate (NMDA) receptor antagonists, and regional anesthesia techniques such as nerve blocks are utilized, but these also have limitations. This underscores the need for complementary non-pharmacological interventions to enhance postoperative pain control and reduce opioid dependence. This study aimed to synthesize evidence on the efficacy of nondrug approaches for managing postoperative pain. The study examined the effects of non-pharmacological interventions such as preoperative patient education, mind-body modalities, and physical therapies. Findings suggest that these approaches can reduce pain intensity, decrease opioid consumption, and enhance recovery outcomes. The study also highlighted the pivotal role of healthcare professionals in implementing these strategies. However, it identified workload constraints and insufficient training as barriers to effective utilization in clinical practice. Integrating non-pharmacological interventions into multimodal pain management regimens can improve postoperative pain control and reduce reliance on opioids. Further research is crucial to definitively establish the efficacy of individual interventions and optimize their combined use in clinical practice. Additionally, enhanced training programs for nurses and initiatives to facilitate the implementation of these strategies are necessary for their successful adoption.

Manual Acupuncture for Postoperative Pain and Recovery after Abdominal Surgeries: A Systematic Review

Introduction: Acupuncture's role in surgical and postoperative contexts is gaining traction. However, the evidence remains patchy and is often of low-grade quality, particularly in the context of postintestinal surgery. Purpose: To assess acupuncture's efficacy in pain relief and functional recovery after abdominal surgery. Methods: We searched PubMed, Cochrane, Web of Science, and Google Scholar for randomized trials using manual acupuncture as the main intervention. Outcomes included postoperative pain, analgesic use, nausea, gastrointestinal (GI) regeneration, and length of hospital stay. For risk of bias assessment Cochrane risk of bias tool 2 was employed. Registered with PROSPERO: CRD42022311718. Results: Of 700 records till May 2023, 8 trials (551 patients; 16-200/trial) were included. Due to factors such as varying experimental settings and unpublished protocols, there was high risk of bias and heterogeneity, making meta-analysis unfeasible. Safety data were documented sufficiently by two trials. However, acupuncture showed marked benefits in pain relief, less analgesic use, fewer nausea cases, and improved GI recovery. One study reported reduced hospitalization time. Conclusion: Due to the varied methodologies and potential biases in existing studies, the definitive effectiveness of acupuncture remains unclear. To confirm the potential benefits of acupuncture as suggested by the reviewed studies, it's imperative to have more standardized study protocols, well-defined interventions and controls, and objective measures of efficacy.

Use of acupuncture among chronic disease patients attending primary healthcare facilities: a cross-sectional study in Korea

BACKGROUND

Given the crucial role of integrating acupuncture treatment into primary care for managing chronic diseases, this study endeavors to identify the utilization of acupuncture among chronic disease patients seeking primary care services in Korea. Additionally, it aims to evaluate their knowledge level and perceptions related to acupuncture use.

METHODS

A descriptive cross-sectional study was conducted among chronic disease patients attending a primary care clinic in Korea. A self-reported questionnaire comprising 37 items was employed to evaluate the utilization of acupuncture treatment. These items covered socio-demographic information, respondents' health status, levels of acupuncture knowledge, and patterns of acupuncture use. Using the SPSS Statistics 26.0 Network Version program, descriptive statistics, a chi-square test, and a logistic regression analysis were performed to identify factors associated with acupuncture treatment.

RESULTS

Out of 370 respondents, 44.3% reported utilizing acupuncture treatment. The most popular reason for the utilization of acupuncture was to enhance the effectiveness of the current treatment. The patients with musculoskeletal disease had the highest utilization rate of 53.2%. The main source of information for acupuncture use was family and friends. The average score for the level of knowledge on acupuncture treatment among the respondents was 65.4%, and the knowledge level of the acupuncture group was high. Potential predictors of acupuncture use included musculoskeletal disease, and intention to recommend acupuncture.

CONCLUSION

This study highlights the widespread acceptance of acupuncture use among patients with chronic diseases in primary healthcare context. Integration of acupuncture into primary care emerges as a viable avenue for effective chronic disease management, and fostering a comprehensive and holistic approach to healthcare.

CLINICAL TRIAL NUMBER

Not applicable.

Prevalence of and factors associated with trauma surgeons' referral and patients' willingness to acupuncture treatment after traumatic rib fractures: A single-center cross-sectional study

Background

Pain after traumatic rib fractures (TRF) detrimentally affects the injured. Multidisciplinary pain management is crucial for patient care. There is little empirical evidence on acupuncture as a multidisciplinary treatment for patients with TRF. This study aimed to illustrate the characteristics of the patients referred for or received acupuncture and explore the associated factors.

Methods

We conducted a cross-sectional study of Korean Trauma Data Bank and electronic medical records of patients aged 19 or older with TRF from August 2016 to October 2021 in the regional trauma center of Pusan National University Hospital. The sociodemographic and clinical characteristics of patients referred for acupuncture by trauma surgeons and those who received acupuncture were analysed descriptively. In multivariable logistic regression analyses, associations between covariates and either surgeon referrals for or patient willingness to receive acupuncture were quantitatively estimated.

Results

Among 2,937 injured patients, trauma surgeons referred 178 (6.1 %) to acupuncture. Among the referred patients, 111 (72.1 %) underwent acupuncture. Patients with polytrauma (aOR 0.46; 0.30 to 0.68) were less likely to be referred to acupuncture, whereas female patients (aOR 3.92, 1.31 to 11.77) were most likely to receive acupuncture.

Conclusions

A small proportion of patients with TRF were referred for acupuncture, but the referred patients were more likely to receive acupuncture. Polytrauma may be an important criterion for referral to acupuncture services from the perspective of trauma surgeons, while the willingness to receive acupuncture may be associated with gender-related factors. Further studies are warranted to investigate the role of acupuncture in the postinjury care of patients with TRF.

Acupuncture in the emergency department (ACUITY): Results from a BraveNet multi-center feasibility randomized controlled trial

Background

Pain plays a significant role in emergency department (ED) visits, however safe and effective nonpharmacologic options are needed. Prior studies of acupuncture in the ED reported pain reduction with minimal side effects, but most were small and single site.

Methods

We conducted ACUITY, a prospectively designed multi-center feasibility RCT. Our goal was to recruit 165 adults with acute non-emergent pain ≥4 on a 0-10-point scale at three EDs affiliated with BraveNet Practice Based Research Network. At baseline and 45-60 min later (post), participants self-assessed their pain and anxiety using a 0-10 rating scale. The primary feasibility outcome was recruitment of participants, whereas secondary outcomes were retention, and participant/provider acceptability.

Results

From May 3, 2021, to September 24, 2022, 632 eligible individuals were approached and 165 enrolled (165/632: 26.1 %), meeting our recruitment goal. Notably, 42.4 % of enrollees were Black/African American, 42.4 % were White/Caucasian, and 13.9 % were Hispanic/Latino. Participants were randomized to Acupuncture (n = 83) or Usual care (n = 82), of which 151 (91.5 %) and 128 (77.6 %) provided pain and anxiety scores at post-treatment and 1-week respectively. Acupuncture was rated acceptable to participants and providers. Mean pain ratings (pre-to-post) were 7.4 (2.2) to 4.8 (2.8) for acupuncture and 7.1 (2.3) to 6.4 (2.5) for usual care. Mean anxiety ratings (pre-to-post) were 4.5 (3.4) to 2.5 (2.6) for acupuncture and 4.1 (3.4) to 3.5 (3.2) for usual care.

Conclusion

Successful completion of ACUITY indicates we have the expertise and preliminary data to conduct a future definitive, multi-center RCT.

Trial registration Clinical trialsgov

NCT04880733.

Therapeutic effects of acupuncture therapy for kidney function and common symptoms in patients with chronic kidney disease: a systematic review and meta-analysis

Purpose: The number of clinical reports of acupuncture therapy in chronic kidney disease (CKD) is gradually increasing. This systematic review and meta-analysis aim to examine the therapeutic role of acupuncture therapy in kidney function and common symptoms in CKD patients.Methods: We searched Embase, PubMed, Scopus, Web of Science, China National Knowledge Infrastructure, WanFang, and WeiPu for randomized controlled trials comparing acupuncture treatment with control or placebo groups. We assessed the effect of acupuncture therapy in CKD patients using a meta-analysis with the hartung-knapp-sidik-jonkman random effects model. In addition, we visualized keyword co-occurrence overlay visualization with the help of VOSviewer software to describe the research hotspots of acupuncture therapy and CKD.Results: A total of 24 studies involving 1494 participants were included. Compared to the control group, acupuncture therapy reduced serum creatinine levels (standardized mean difference [SMD]: -0.57; 95% CI -1.05 to -0.09) and relieved pruritus (SMD: -2.20; 95% CI -3.84, -0.57) in patients with CKD, while the TSA showed that the included sample size did not exceed the required information size. The included studies did not report acupuncture-related adverse events.Conclusions: Acupuncture is an effective and safe treatment for improving kidney function and relieving pruritic symptoms in patients with CKD, but the very low evidence may limit this conclusion. The TSA suggests that high-quality trials are needed to validate the efficacy of acupuncture therapy.

Effect of auriculotherapy on labor duration: systematic review and meta-analysis

Length of labor is one of the factors contributing to maternal and neonatal childbirth outcomes. Auriculotherapy is a potential therapeutic intervention for reducing labor duration. This systematic review aims to evaluate the efficacy of auriculotherapy in shortening labor time.This systematic review and meta-analysis included randomized controlled trials published from inception until July 2024. Scopus, Cochrane Library, Web of Science, Embase, and PubMed were searched for eligible studies. Article screening was performed using Endnote X8. Data analysis and assessment of the risk of bias were performed by Review Manager 5.3. Analysis of pooled data was performed using fixed and random effect models. Five studies (n = 433 participants) were included in the meta-analysis from an initial pool of 150 articles. The participants' mean age was 25.07 ± 4.52. Auriculotherapy reduced the length of the active and second phases of labor by approximately sixty (MD = -63.54; 95 percent CI: -84.47, -42.62; p < .00001) and seven minutes (MD = -7.67; 95 percent CI: -13.46, -1.89, p = .009), respectively. Auriculotherapy was found to significantly decrease the duration of the active and second phases of labor. However, it is not possible to generalize the results and further high-quality studies involving more individuals from various socioeconomic backgrounds are needed to provide support for these findings.

Bridging the Gap: Promoting Interventional Pain Medicine as a Future for Family Physicians

The use of interventional pain medicine (IPM) has been growing over the past few years, offering relief to patients suffering from acute and chronic pain who have failed conservative therapies. Pain is one of the top complaints that family physicians encounter, yet there is no official pain medicine (PM) fellowship or recognized training program that favors family medicine graduates. Although family medicine residency programs allot a certain amount of time to teaching trainees in PM, this is considerably insufficient and does not dedicate ample time for procedural treatments. This review explains the increasing demand for IPM and provides several arguments for family physicians to provide all aspects of PM, including interventional treatments. It is recommended that pain fellowships recognize family physicians as being ideal candidates for their programs and identify their potential and competencies to perform interventional procedures.

Recent advances in acupuncture for pain relief

Introduction

Acupuncture therapy has achieved global expansion and shown promise for health promotion and treatment of acute/chronic pain.

Objectives

To present an update on the existing evidence base for research and clinical practice supporting acupuncture analgesia.

Methods

This Clinical Update elaborates on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care "Factsheet Acupuncture for Pain Relief" and reviews best evidence and practice.

Results

Acupuncture is supported by a large research evidence base and growing utilization. Mechanisms of acupuncture analgesia include local physiological response at the needling site, suppression of nociceptive signaling at spinal and supraspinal levels, and peripheral/central release of endogenous opioids and other biochemical mediators. Acupuncture also produces pain relief by modulating specific brain networks, integral for sensory, affective, and cognitive processing, as demonstrated by neuroimaging research. Importantly, acupuncture does not just manage pain symptoms but may target the sources that drive pain, such as inflammation, partially by modulating autonomic pathways. Contextual factors are important for acupuncture analgesia, which is a complex multifaceted intervention. In clinical practice, historical records and many providers believe that acupuncture efficacy depends on specific acupoints used, the technique of needle placement and stimulation, and the person who delivers the procedure. Clinical research has supported the safety and effectiveness of acupuncture for various pain disorders, including acupuncture as a complementary/integrative therapy with other pain interventions.

Conclusion

Although the quality of supportive evidence is heterogeneous, acupuncture's potential cost-effectiveness and low risk profile under standardized techniques suggest consideration as a neuromodulatory and practical nonpharmacological pain therapy.

Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes.

OBJECTIVES

This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach.

RESULTS

A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %).

CONCLUSION

This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines

Background

Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported.

Methods

ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity.

Results

Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form.

Conclusion

To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs.

Protocol registration

The protocol of this study is registered at clinicaltrials.gov: NCT04880733.

Nanotechnology for Pain Management

Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.

Pain Management Strategies in Intensive Care Unit: Challenges and Best Practice

Pain management in the ICU (intensive care unit) is a very complex problem which involves a wide variety of conditions, lack of sufficient tools for use, and high personnel to patient ratio. In the last three decades, pain as a clinical issue has become well analyzed, and treatment protocols based on scientific evidence have been established. Besides medication, some non-pharmacological methods such as music therapy, relaxation, and massage have been proven to be very much practical and manageable in pain management of ICU. The main opioids are utilized predominantly due to their power but NSAIDs and local anesthesia are combined with opioids with the aim to reduce the pain as much as possible. Yet more research now has to prove that pain evaluation and management is effective. This article discusses on the issues and the best approaches to solving them when managing pain in ICU patients.

Research hotspots and trends on acupuncture treatment for headache: a bibliometric analysis from 2003 to 2023

Background

While acupuncture treatment has gained extensive usage in addressing headaches, there remains a notable gap in the literature analysis for this field. Therefore, this study aims to conduct a literature review using Citespace, VOSviewer, and Bibliometrix, aiming to examine the current status, strengths, and potential future directions in the utilization of acupuncture for headache treatment.

Methods

Relevant literature on acupuncture treatment for headaches between 2003 and 2023 was retrieved from the Web of Science (WoS) core database. Utilizing CiteSpace 6.1.R6, VOSviewer 1.6.18, and Bibliometrix 4.1.4, we conducted bibliometric analyses across various categories, including countries/regions, institutions, authors, journals, references, and keywords.

Results

A total of 808 research reports were included. China and the United States have significantly contributed to this field. Chengdu University of Chinese Medicine holds the record for the highest number of published papers. Liu Lu has the highest publication output, while Linde K has the highest citation rate. MEDICINE leads in publication frequency, while CEPHALALGIA holds the highest citation rate. The Long-term Effect of Acupuncture for Migraine Prophylaxis a Randomized Clinical Trial is the most cited reference. Migraine was the most researched type. Filiform needle acupuncture was the most widely used stimulation method. The safety and efficacy of acupuncture have received significant attention. Modern mechanism research shows that depression, brain functional connectivity, and neuroimaging technology have become research hotspots in the acupuncture treatment of headaches.

Conclusion

Acupuncture treatment for headaches has established a stable trend with a promising developmental trajectory. Research in this field mainly focuses on different acupuncture prevention and treatment for various types of headaches, the safety and efficacy of acupuncture, etc. Research on the mechanism of action mainly focuses on interpreting bidirectional and holistic regulation between pain and emotion by acupuncture and the regulation of brain function connection and neuroimaging technology by acupuncture. Future research should expand on the advantages and indications of acupuncture treatment for different headaches and their modern mechanisms.

Acupuncture in management of acute dental pain - A systematic review and meta-analysis

Acute dental pain is a common issue leading to dental consultation. Besides causal therapy, patients are treated with acupuncture, but efficacy in acute dental pain is still not clarified. We aimed to evaluate results of recent research to estimate the efficacy of acupuncture compared to pain-relieving approaches in treatment of acute dental pain. A systematic review of controlled trials being published between database inception and 2020 were conducted to evaluate the efficacy of acupuncture (alone or as complementary therapy) compared to local anesthesia or conventional analgesic medications in acute dental pain (intraoperatively and postoperatively) and to clarify whether acupuncture reduces the use of postoperative analgesic medications. Of 1672 publications, 23 publications met the inclusion criteria. From these, 11 randomized controlled trials (n = 668) reported on the efficacy of acupuncture on postoperative acute dental pain. Patients, who received acupuncture, showed lower pain scores postoperatively compared to sham acupuncture (Relative Risk -0.77, 95% Confidence interval -1.52 to -0.03). Overall, the results suggest a potential role of acupuncture in improving acute dental pain intraoperatively and postoperatively as well as improving the efficacy of local anesthesia, but the results are limited due to methodological shortcomings emphasizing the necessity for future high-quality research.

Effects of Electrical Stimulation on Delayed Onset Muscle Soreness (DOMS): Evidences from Laboratory and In-Field Studies

Intense, long exercise can increase oxidative stress, leading to higher levels of inflammatory mediators and muscle damage. At the same time, fatigue has been suggested as one of the factors giving rise to delayed-onset muscle soreness (DOMS). The aim of this study was to investigate the efficacy of a specific electrical stimulation (ES) treatment (without elicited muscular contraction) on two different scenarios: in the laboratory on eleven healthy volunteers (56.45 ± 4.87 years) after upper limbs eccentric exercise (Study 1) and in the field on fourteen ultra-endurance athletes (age 47.4 ± 10.2 year) after an ultra-running race (134 km, altitude difference of 10,970 m+) by lower exercising limbs (Study 2). Subjects were randomly assigned to two experimental tasks in cross-over: Active or Sham ES treatments. The ES efficacy was assessed by monitoring the oxy-inflammation status: Reactive Oxygen Species production, total antioxidant capacity, IL-6 cytokine levels, and lactate with micro-invasive measurements (capillary blood, urine) and scales for fatigue and recovery assessments. No significant differences (p > 0.05) were found in the time course of recovery and/or pre-post-race between Sham and Active groups in both study conditions. A subjective positive role of sham stimulation (VAS scores for muscle pain assessment) was reported. In conclusion, the effectiveness of ES in treating DOMS and its effects on muscle recovery remain still unclear.

When Patients' Assessments of Treatment for Subjective Symptoms are At Odds with Authoritative Assessments in the Biomedical Literature: The Case of Patients Treated with Acupuncture for Low Back Pain in a Traditional Chinese Medicine Clinic in China (and Story of a Bewildered Chicken)

Assessments of treatments for 'subjective symptoms' are problematic and potentially contentious. These are symptoms without ascertainable pathophysiology, also referred to as 'medically unexplained.' Treatments of them may be assessed from different perspectives, and an assessment as seen from one perspective may be discrepant with an assessment as seen from another perspective. The observational study described in the paper represents one perspective. Patients in the study were treated with acupuncture for the subjective symptom of low back pain in a Traditional Chinese Medicine Clinic in China; acupuncture is a form of TCM, which is indigenous to China. Shortly after treatment began and six months afterward, patients reported 'clinically important improvements' on a variety of standard, cross-culturally validated outcome measures, including pain intensity, physical functioning, and emotional functioning; this assessment is consistent with numerous assessments of acupuncture in China and other Southeastern Asian countries. On the other hand, clinical trials represent another perspective from which to assess acupuncture. Although assessments based on trials are not uniform, several assessments based on them, including those published in journals such as Lancet and New England Journal of Medicine, conclude that acupuncture is not effective. These trials, however, were mainly situated in the U.S., western European countries, and other WEIRD (Western, Educated, Industrialized, Rich, Democratic) countries. This is notable, because the population of China, the indigenous context of acupuncture, is greater than populations of WEIRD countries combined. Patients' expectations of a treatment such as acupuncture and their prior familiarity with it vary among contexts, and patients' experiences of treatment outcomes may vary accordingly. In short, although clinical trials constitute a test of truth in biomedicine and inform authoritative assessments in WEIRD countries, they do not necessarily represent the truth from the perspective of those experiencing outcomes of especially indigenous treatments for subjective symptoms in non-WEIRD contexts.

Non-Pharmacological Interventions for Pain Management in Hemodialysis: A Narrative Review

This narrative review aims to summarize non-pharmacological interventions for pain management in hemodialysis patients, assessing their potential benefits and limitations in enhancing patient well-being and quality of life. We reviewed the current literature on five primary non-pharmacological interventions: acupuncture, cognitive behavioral therapy, relaxation techniques, virtual reality, and alternative methods such as transcutaneous electrical nerve stimulation, music therapy, and aromatherapy. We analyzed the evidence regarding their effectiveness, feasibility, and optimal implementation strategies. The existing evidence supports the potential benefits of these interventions in managing pain and improving the well-being of hemodialysis patients. However, further high-quality research is needed to confirm their effectiveness, establish implementation best practices, and assess their long-term impact on patient outcomes. Non-pharmacological interventions hold promise for pain management in hemodialysis patients. Additional research is required to optimize these interventions and validate their effectiveness, contributing to comprehensive pain management strategies for this vulnerable patient population.

Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial

BACKGROUND

Post-operative pain of endoscopic submucosal dissection (ESD) is always be overlooked and undertreated by endoscopists. However, the incidence of moderate to severe pain after ESD is as high as 44.9% to 62.8%, which can greatly affect the patient's recovery, reduce their satisfaction, and extend their hospital stay. Transcutaneous electrical acupoint stimulation (TEAS) have been shown to reduce postoperative pain and enhance gastrointestinal (GI) function recovery in patients undergoing abdomen surgery. However, there is no evidence regarding on the effect of TEAS on post-operative pain and complications in patients undergoing ESD. Therefore, we aim to investigate whether perioperative TEAS treatment is superior to the sham acupuncture in terms of post-ESD pain and GI function recovery.

METHODS

This study is a prospective, randomized controlled trail, which is single-blinded and in single center. A total of 120 patients undergoing elective gastric and esophageal ESD surgery in Beijing Friendship Hospital, Capital Medical University, will be involved in this study. These individuals will be stratified according to the type of ESD surgery (i.e. gastric or esophageal procedure) and be randomly divided into two groups. L14, PC6, ST36 and ST37 will be stimulated at the TEAS treatment group, and the control group will receive simulation at four sham acupoints. The primary outcome is post-EDS VAS score at the time of entering PACU, 10 min, 20 min, 30 min, 1 h, 2 h, 4 h, 6 h, 18 h, 24 h, 48 h after the surgery. The secondary outcomes include the anesthesia-associated parameters, sedation score, nausea and vomiting score, shivering score, recovery of gastrointestinal function, satisfaction of patients to anesthesia, incidence of postoperative complications, QLQ-C30 life quality scale, and the economic indicators.

DISCUSSION

The results of this study will confirm that continuous preventive application of TEAS can alleviate the postoperative pain among patients with gastric and esophageal ESD surgery and accelerate the recovery of post-ESD gastrointestinal function.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100052837, registered on November 6, 2021. http://www.chictr.org.cn/showproj.aspx?proj=135892 .

Electroacupuncture for Pain Outcomes in a Trauma Center's Acute Pain Service: A Retrospective Observational Study

Background

Evidence for acupuncture to treat pain is growing. Electrostimulation of acupuncture needles (electroacupuncture) is common for pain and is thought to augment the therapeutic effect.

Objectives

To examine the association of pain outcomes after a single acupuncture session with electrostimulation included (EA) compared with no electrostimulation included (NEA).

Methods

A retrospective observational study was conducted using electronic health records of acupuncture sessions for adults with acute pain under the care of an acute pain service. Paired t-test and linear regression were used to report pain intensity changes after a single acupuncture session and by including EA. Ordered logistic regression was used to report categorical pain relief. Logistic regression was used to explore the odds of adding EA and the patient's age, gender, and pretreatment pain.

Results

From July 24, 2017, through November 9, 2020, 465 acupuncture sessions recorded EA (n = 194), or NEA (n = 271). Acupuncture, independent of EA status, reduced pain intensity by a mean 2.5 points. EA was associated with a mean 0.38-point reduction in pain intensity more than NEA (confidence interval [95% CI]: -0.75 to -0.01). Among sessions reporting categorical pain relief (n = 415), higher relief was more likely with EA (odds ratio = 2.16, 95% CI: 1.52-3.08). There was no association between EA and the patient's age, gender, and pretreatment pain intensity.

Conclusions

After a single acupuncture session, both EA and NEA reduced pain intensity. Higher categorical pain relief was reported with EA, though the clinical meaning is uncertain. Future research should focus on well-defined populations for electroacupuncture and factors for including electrostimulation.

Ultrasound-Guided Electroacupuncture for Thoracic Myofascial Pain Syndrome: A Case Report

Myofascial pain syndrome is a painful condition characterized by trigger points in muscles that can be treated effectively with acupuncture. While cross-fiber palpation can help localize trigger points, needle accuracy may be limited and accidental puncture of delicate structures, such as the lung, is a risk, as evidenced by reports of pneumothorax after acupuncture. Ultrasound imaging can help in reducing the risk of iatrogenic pneumothorax from needling, but there is a paucity of papers describing the use of ultrasound imaging during acupuncture. We present a report on electroacupuncture treatment for myofascial pain syndrome using real-time ultrasound guidance, aimed at avoiding accidental puncture of the pleura when targeting deep muscle layers in the thoracic region.

Comparative effectiveness of external therapies of traditional Chinese medicine and surgical treatments in pain management of postherpetic neuralgia: A protocol for a systematic review and network meta-analysis

BACKGROUND

As the most common long-term complication of herpes zoster (HZ), postherpetic neuralgia (PHN) is characterized by chronic, persistent, and debilitating neuropathic pain. PHN seriously harms human health and currently becomes a topic of clinical importance. To date, the common methods of pain management in PHN include external therapies of traditional Chinese medicine and surgical treatments. However, there is no high-quality or direct evidence of their comparative effectiveness. This review aims to provide a network meta-analysis to compare the efficacy of external therapies of traditional Chinese medicine and surgical treatments in the pain management of PHN.

METHODS

Databases such as PubMed, Cochrane Central Register of Controlled Trials, EMBASE, China National Knowledge Infrastructure, China Biology Medicine Disc will be searched for relevant randomized controlled trials to obtain literatures on the treatment of PHN with external therapies of traditional Chinese medicine and surgical treatments, and clinical randomized controlled trials will be screened out from their inception to August 5, 2022. The participant intervention comparator outcomes of this study are as flowing: P, patients with PHN; I, external therapies of traditional Chinese medicine and surgical treatments; C, no treatment, pharmacological placebo, treatment as usual or sham acupuncture groups; O, primary outcome is pain intensity, and secondary outcomes are onset of pain relief time, quality of life, therapeutic effective rate and reverse effects. Cochrane Risk of Bias Tool will be used in assessing literature's quality. Network meta-analyses will be conducted to generate estimates of comparative effectiveness of each intervention class and rankings of their effectiveness, in terms of pain management.

RESULT

This systematic review and network meta-analysis will provide evidence of the efficacy of different therapeutic methods for pain management in PHN, to show which forms of therapy are more commonly used with higher effectiveness.

DISCUSSION

The results will systematically provide suggestions for medical practitioners to choose effective, time-saving and economical pain management method for PHN.

Case report: Electroacupuncture for acute pain flare-up of knee osteoarthritis

Acute pain flare-up of knee osteoarthritis (KOA) is a common disease in orthopedics and is mainly treated with analgesic drugs. Patients usually refuse to take western medicines orally owing to gastrointestinal side effects or unsatisfactory treatment results. We report the case of a 69-year-old woman who had an acute pain flare-up of right KOA induced by long-distance walking. As the patient refused medication, we used electroacupuncture (EA) to relieve her symptoms. EA with a 2-Hz frequency and a 1–2-mA intensity had an analgesic effect on the acute pain flare-up of KOA. After 12 weeks of EA intervention, the bone marrow edema-like lesions (BMLs) improved significantly, as depicted on magnetic resonance imaging of the knee joint. However, more powerful evidence is needed to understand the mechanism of the EA technique that alleviates BMLs of KOA.